Name: Abbey Animal Hospital
Address: 1949 Lynnhaven Pkwy #1524, Virginia, VA23453
Telephone: +1-(757) 471-1003
Price range: $$

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Name*
First Last
Pet’s Name*
Pet’s Age*
Today’s Date*
How did you hear of Abbey Animal Hospital?*
Breed*
Birth date*
Age obtained*
Sex*
- M
- F
Pregnant?*
- Yes
- No
Spayed/Neutered?*
- Yes
- No
If yes, at what age:
Weight*
Where did you obtain this pet:*
- Breeder
- Friend
- Pet Store
- Humane Shelter
- Rescue
Behavior Problems of parents or littermates, if known*
Your primary veterinarian’s name:
Name of Clinic or Hospital
Phone
Principal Behavioral Complaint
Summarize the primary behavior problem in one sentence:*
How would you describe the severity of this problem?*
- Mild
- Moderate
- Severe
Have you considered euthanasia?*
- Yes
- No
Please Comment:
Describe the last two incidents in as much detail as possible. Include an approximate date of each incident:*
FREQUENCY
Please indicate the number of times the problem has occurred in each of the times indicated below:
PAST WEEK*
PAST MONTH*
PAST YEAR*
Since you’ve owned*
BACKGROUND INFORMATION
At what age was your pet when the problem began?*
Were there any changes in the home at that time?*
List techniques you have used to correct the problem*
TECHNIQUES
What techniques (if any) have helped?*
What techniques have made the problem worse?*
Have any drugs been tried for this problem? If yes, what?*
What do you think is the reason for your cat's problem?*
PERONS LIVING IN THE HOUSEHOLD
List each person living in the household, including age, sex, time away from home (example 9am-5pm), and comments on that person’s relationship with your pet (for exam: “feeds cat” or “is afraid of cat”)*
(Please list the NAME, AGE, SEX, HOURS AWAY, RELATIONSHIP W/ Pet)
PETS LIVING IN THE HOUSEHOLD
List all other pets in the household. Comment on the relationship between the cat with the behavior problem and your other pets (for example: “get along” or “dominates cat.”)*
(Please list the NAME, SPECIES, BREED, AGE, SEX, COMMENTS)
DIET
Brand Name (WET Cat FOOD )
How Often Given (WET Cat FOOD )
Desire For This Type Of Food (WET Cat FOOD)
- Mild
- Moderate
- Strong
Brand Name (DRY Cat FOOD )
How Often Given (DRY Cat FOOD )
Desire For This Type Of Food (DRY Cat FOOD)
- Mild
- Moderate
- Strong
Brand Name (ADDITIONAL Cat FOOD )
How Often Given (ADDITIONAL Cat FOOD )
Desire For This Type Of Food (ADDITIONAL Cat FOOD)
- Mild
- Moderate
- Strong
Brand Name (TABLE SCRAPS / PEOPLE FOOD )
How Often Given (TABLE SCRAPS / PEOPLE FOOD )
Desire For This Type Of Food (TABLE SCRAPS / PEOPLE FOOD )
- Mild
- Moderate
- Strong
Brand Name (TREATS TYPE 1 )
How Often Given (TREATS TYPE 1 )
Desire For This Type Of Food (TREATS TYPE 1 )
- Mild
- Moderate
- Strong
Brand Name (TREATS TYPE 2 )
How Often Given (TREATS TYPE 2 )
Desire For This Type Of Food (TREATS TYPE 2 )
- Mild
- Moderate
- Strong
Brand Name (SUPPLEMENTS / VITAMINS )
How Often Given (SUPPLEMENTS / VITAMINS )
Desire For This Type Of Food (SUPPLEMENTS / VITAMINS )
- Mild
- Moderate
- Strong
LOCATION/ACTIVITY/EXERCISE
AMOUNT OF TIME per DAY or PER WEEK CAT SPENDS at this Site/Activity (In HOUSE, PER DAY )
INDICATE LOCATION (loose in house, in kitchen, in crate or pen, at park, ect.) (In HOUSE, PER DAY )
INDICATE WHAT CAT WEARS (nothing, collar, harness, chock chain, prong collar, halter, ect.) (In HOUSE, per day)
AMOUNT OF TIME per DAY or PER WEEK CAT SPENDS at this Site/Activity (OUTSIDE PER DAY)
INDICATE LOCATION (loose in house, in kitchen, in crate or pen, at park, ect.) (OUTSIDE PER DAY)
INDICATE WHAT CAT WEARS (nothing, collar, harness, chock chain, prong collar, halter, ect.) (OUTSIDE PER DAY)
AMOUNT OF TIME per DAY or PER WEEK CAT SPENDS at this Site/Activity (ALONE PER DAY)
INDICATE LOCATION (loose in house, in kitchen, in crate or pen, at park, ect.) (ALONE PER DAY)
INDICATE WHAT CAT WEARS (nothing, collar, harness, chock chain, prong collar, halter, ect.) (ALONE PER DAY)
AMOUNT OF TIME per DAY or PER WEEK CAT SPENDS at this Site/Activity (PLAYTIME, per day )
INDICATE LOCATION (loose in house, in kitchen, in crate or pen, at park, ect.) (PLAYTIME, per day )
INDICATE WHAT CAT WEARS (nothing, collar, harness, chock chain, prong collar, halter, ect.) (PLAYTIME, per day )
INDICATE LOCATION (loose in house, in kitchen, in crate or pen, at park, ect.) (Jogging or structured exercise, per week )
INDICATE LOCATION (loose in house, in kitchen, in crate or pen, at park, ect.) (ASLEEP)
INDICATE LOCATION (loose in house, in kitchen, in crate or pen, at park, ect.) (ASLEEP)
INDICATE WHAT CAT WEARS (nothing, collar, harness, chock chain, prong collar, halter, ect.) (ASLEEP)
What is your pet’s favorite toy?*
What is your pet’s favorite game?*
Are you able to medicate your cat yourself?*
- Yes
- No
What is the best way for you to give your cat medication?*
HANDLING
Check how your cat responds to the following tasks
Nail Trim*
- NO REACTION
- AVOIDS
- RESISTS
- GROWLS
- SNAPS
Comment*
Greeting you*
- NO REACTION
- AVOIDS
- RESISTS
- GROWLS
- SNAPS
Comment*
Greeting Stranger*
- NO REACTION
- AVOIDS
- RESISTS
- GROWLS
- SNAPS
Comment*
Bathing*
- NO REACTION
- AVOIDS
- RESISTS
- GROWLS
- SNAPS
Comment*
Petting, Stroking*
- NO REACTION
- AVOIDS
- RESISTS
- GROWLS
- SNAPS
Comment*
Grooming*
- NO REACTION
- AVOIDS
- RESISTS
- GROWLS
- SNAPS
Comment*
Being Picked Up*
- NO REACTION
- AVOIDS
- RESISTS
- GROWLS
- SNAPS
Comment*
CORRECTIONS
Indicate any correction techniques you have used and indicate their effects on your cat’s behavior
TYPE of Correction ( Time Out )*
- Yes
- No
RESULT
- Improved the Problem
- No Effect on the Problem
- Made the problem worse
TYPE of Correction ( Water Sprayer )*
- Yes
- No
RESULT
- Improved the Problem
- No Effect on the Problem
- Made the problem worse
TYPE of Correction ( Verbal Scolding )*
- Yes
- No
RESULT
- Improved the Problem
- No Effect on the Problem
- Made the problem worse
TYPE of Correction ( Noisemaker Shaker can/siren )*
- Yes
- No
RESULT
- Improved the Problem
- No Effect on the Problem
- Made the problem worse
TYPE of Correction ( Lifting by Scruff )*
- Yes
- No
RESULT
- Improved the Problem
- No Effect on the Problem
- Made the problem worse
TYPE of Correction ( Spanking )*
- Yes
- No
RESULT
- Improved the Problem
- No Effect on the Problem
- Made the problem worse
Other TYPE of Correction
HOUSE SOILING
Are you having a house-soiling problem with your cat?*
- Yes
- No
Is the house-soiling problem related to:*
- URINE
- FECES
- BOTH
Have you ever seen your cat spray urine?*
- Yes
- No
How often are you finding urine or feces outside the litter box?*
“CULPRIT”: If you have more than one cat, which of your cats is house-soiling?*
How do you know this cat is the “culprit”?*
LOCATION: In what room or rooms does your cat house-soil?*
In what room or rooms (to which your cat has access) does house-soiling NEVER occur?*
SUBSTRATE: What is your cat’s favorite “surface” for house-soiling (i.e.: carpet, throw rugs, bed, laundry, etc…)*
TEMPORAL PATTERN: what time of day is your cat most likely to house-soil?*
LITTER BOX DATA
Number of litter boxes in your home:*
Number of litter boxes in your home:*
How often are your litter boxes scooped? Completely changed?*
What type of litter box(es) do you use? (i.e.: plain, covered, electronic)*
What type of litter do you use? Brand and Type (i.e.: clay, clumping, newspaper)*
Have you tried other litters? If so, which type and brand?*
Do you use a litter box liner?*
Does your cat dig in the litter box BEFORE eliminating?*
Does your cat bury urine and/or feces (at least some of the time) after using the litter box?*
Aggression
TARGET: To whom is the aggression directed?*
- PEOPLE
- OTHER CAT(S)
- BOTH
When approached by person*
- No Response
- Hisses
- Meows
- Snarls
- Bites
When picked up*
- No Response
- Hisses
- Meows
- Snarls
- Bites
When petted/groomed*
- No Response
- Hisses
- Meows
- Snarls
- Bites
When scolded or spanked*
- No Response
- Hisses
- Meows
- Snarls
- Bites
When cat sees other cats in household*
- No Response
- Hisses
- Meows
- Snarls
- Bites
When cat sees other cats outside To restrain (i.e. at veterinarians)*
- No Response
- Hisses
- Meows
- Snarls
- Bites
OTHER (describe):
Has your cat ever been reported to local authorities or public health department for biting?*
- Yes
- No
Is your pet currently in a 10-day quarantine for biting?*
- Yes
- No
Any other problems or issues you would like to go over with the Dr.?
SYMPTOMS
TECHNIQUES USED BEFORE TO RESOLVE
OTHER
MEDICAL HISTORY
Is your pet up-to-date on routine vaccinations, including rabies?*
- Yes
- No
Medication #1: NAME OF MEDICATION, DOSE (mg) or Amount, HOW OFTEN?, REASON GIVEN?
Medication #2: NAME OF MEDICATION, DOSE (mg) or Amount, HOW OFTEN?, REASON GIVEN?
Medication #3: NAME OF MEDICATION, DOSE (mg) or Amount, HOW OFTEN?, REASON GIVEN?
OTHER
MEDICAL PROBLEMS:
Please list any medical problems your pet has had recently (within the last year or so)
CHRONIC?
- Yes
- No
PROBLEM? DATES IF KNOWN?
CHRONIC?
- Yes
- No
PROBLEM? DATES IF KNOWN?
CHRONIC?
- Yes
- No
PROBLEM? DATES IF KNOWN?
CHRONIC?
- Yes
- No
PROBLEM? DATES IF KNOWN?
Please add any addition information or comments:

Canine Behavioral History Form

Principal Behavioral Complaint

FREQUENCY

BACKGROUND INFORMATION

TECHNIQUES

PERONS LIVING IN THE HOUSEHOLD

PETS LIVING IN THE HOUSEHOLD

DIET

LOCATION/ACTIVITY/EXERCISE

HANDLING

CORRECTIONS

HOUSE SOILING

LITTER BOX DATA

Aggression

MEDICAL HISTORY

MEDICAL PROBLEMS:

Have Questions?
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Canine Behavioral History Form

Principal Behavioral Complaint

FREQUENCY

BACKGROUND INFORMATION

TECHNIQUES

PERONS LIVING IN THE HOUSEHOLD

PETS LIVING IN THE HOUSEHOLD

DIET

LOCATION/ACTIVITY/EXERCISE

HANDLING

CORRECTIONS

HOUSE SOILING

LITTER BOX DATA

Aggression

MEDICAL HISTORY

MEDICAL PROBLEMS:

Have Questions? We’ll Reply Quickly.

This site uses tracking technologies

Accessibility Tools

Have Questions?
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